<i>The invisibility of Amazonian singularities in the design and delivery of Primary Health Care (PHC) services: A case study in the rural riverside area of Manaus (AM)</i>

Sousa, Amandia; Fonseca, Fernanda; Bousquat, Aylene

doi:10.1590/S0104-12902023220612en

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Dossier • Saude soc. 32 (2) • 2023 • https://doi.org/10.1590/S0104-12902023220612en copy

The invisibility of Amazonian singularities in the design and delivery of Primary Health Care (PHC) services: A case study in the rural riverside area of Manaus (AM) ¹ 1 Aylene Bousquat is a productivity fellow by the National Council for Scientific and Technological Development (CNPq-Brasil). Amandia Braga Lima Sousa was a PhD student by the National Council for Scientific and Technological Development (CNPq-Brasil).

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Abstract

The Amazon region encompasses a heterogenous territory with singular geographic features, that harbous different vulnerable populations, which require the development of abilities and innovations by health services. However, answers to this challenge become even more distant in the face of a marketing logic that tends to make differences invisible and privilege certain territories. In this scenario, our study analyzed the implementation of a Basic River Health Unit (UBSF), seeking to understand how the needs and singularities of riverside rural areas are included in the planning and execution of health services. To that end, interviews with health services managers and professionals and observations of health care professionals during daily activities were carried out. The results showed the forecast of services, with specific formats and resources for the Amazonian fluvial areas, was an opportunity for the specificities of the region to be evidenced and for more resources, including financial ones, being considered for these localities. However, they also showed that the services offered are still planned in a hierarchical way and organized and executed for urban areas, which points to the need for adaptations.

Keywords:
Rural Health; Primary Health Care; Health Services Administration; Health Equity; Amazon

Categories	Summary of emerging contents
Organization/Planning	Concern to comply federal guidelines; same goals foreseen for the urban area; focus on health in urban areas; focus on logistics issues; planning based on inconsistent data on the population; organization/planning of actions centralized in the health disctict headquarters t; weaknesses in interaction with the population; opening initiatives for the participation of the population; conflicts between managers and professionals.
Adaptation of actions to the singularities of the Amazon territory	Increasing the number of services as a solution; innovations created to meet the specificities; focus on logisticals issues; recognition of the need for more time of the team in the territories; difficulties in communication with users; difficulties due to the constant mobility of the population; difficulties at work due to the lack of technologies; need for more funding; timely contact with rural areas ; recognition of the importance of the territory conditions; recognition of differences; recognition of the effort required of professionals due to the specificities; they recognize that it is important the ACS to live in the local.
Monitoring/Evaluation	Same goals foreseen for urban locations; evaluates current monitoring as good; evaluates current monitoring aspoor; problems in monitoring due to limited technology; there are spaces for supervision and exchange between managers and professionals; difficulties with population data; implementation of monitoring under construction.

Categories	Summary of emerging contents
Relationship with management	They believe that different financial compensation is necessary because of their work; they complain about not having space to participate in the construction of the models; conflicting relationship; they feel invisible to management; managers who do not visit rural areas and do not know the reality; management sees the work of the rural area as the same as that of the urban area; high turnover of managers; monthly meetings only for administrative issues and accountability.
Adaptation of actions to the place	ACSs report that they have carried out different training; UBSF professionals complain about the lack of training, because they had not have specific training for the rural area; they claim that they need better training to carry out their activities; they listen to the people of the place; they feel the need to have a greater scope; lack of strategies with the use of technology; they report adaptating some actions; carrying out a survey on the population; ACS demonstrate knowledge of the population with which they work; UBSF professionals admit that they need to know more about the population; limitations of the population for participation; difficulties with population turnover; they recognize that drought or flood require different strategies; little appreciation of the knowledge of ACSs; they need specific training towork in rural areas; previous experience as a fundamental element.
Work process	They seek to be more resolutive; they feel the need to act with a greater scope; they recommend a biomedical action; the performance of ACSs is broader; they work with medicines in addition to those available in terrestrial health units; they work with the protocols of the Ministry of Health; professionals, center director and ACSs resent that they can no longer act with curative procedures; rules for acting are unclear; they understand that the proposed model has limitations; the adaptations they make to provide services are not officialized; recognize that the time they stay in the localities is short for what should be done; periods of drought and river flooding interfere with the performance of services; ACSs are those who make visits to the locality’s households; absence of technologies; lack of medicines and cleaning material in the PS; uncomfortable and risky conditions experienced in the UBSF; lack of fuel to work; material to small emergency procedures is no longer sent to the PS; the boat used by ACSs for home visits is of their property; they report little turnover, they are usually the same professionals.
Satisfaction with the performance model	They recognize that not all residents of the area have access to services; the lenght of time that the UBSF stays in the community is insufficient; difficulties with referral; feel that this is the only way to provide care; need for professionals with different backgrounds/specialties; difficulties in monitoring people; recognize limitations of the care model; believe that care is better than in the urban area; consider it fundamental to recognize that no community is the same as another.

Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. Av. dr. Arnaldo, 715, Prédio da Biblioteca, 2º andar sala 2, 01246-904 São Paulo - SP - Brasil, Tel./Fax: +55 11 3061-7880 - São Paulo - SP - Brazil
E-mail: saudesoc@usp.br

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[1] Correspondence: Amandia Sousa. Rua Teresina, 476. Adrianópolis. Manaus - AM CEP: 69.057-070